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Revista Brasileira de Anestesiologia 575

Vol. 57, N
o
5, Setembro-Outubro, 2007
Rev Bras Anestesiol ARTIGO DE REVISO
2007; 57: 5: 575-587 REVIEW ARTICLE
RESUMO
Silva YP, Gomez RS,

Mximo TA, Silva ACS Sedao e Analgesia
em Neonatologia.
JUSTIFICATIVA E OBJETIVOS: A importncia do estudo da dor em
Neonatologia se deve ao fato de que a sensao de dor e estresse
significa sofrimento e desconforto para os recm-nascidos e, ape-
sar desse conhecimento, pouco tem sido feito para minimiz-los.
Nessa reviso foram discutidas: a preveno da dor, as medidas
no-farmacolgicas e farmacolgicas para o seu tratamento e a
sedao em recm-nascidos.
CONTEDO: Vrias so as medidas no-farmacolgicas que po-
dem ser tomadas com intuito de prevenir a dor nas Unidades de
Terapia Intensiva Neonatal e tambm para tornar o ambiente mais
humanizado e menos estressante para os pacientes e seus fami-
liares. O tratamento da dor no recm-nascido consiste em medidas
no-farmacolgicas (suco no-nutritiva, glicose) e farmaco-
lgicas (analgsicos no-opiides, opiides e anestsicos locais).
A sedao em recm-nascidos produzida por frmacos que agem
diminuindo a atividade, a ansiedade e a agitao do paciente, po-
dendo levar amnsia de eventos dolorosos ou no-dolorosos. A
sedao pode ser feita pela administrao de hidrato de cloral,
barbitricos, propofol e benzodiazepnicos.
CONCLUSES: A preveno da dor e a indicao de analgesia
devem ser individualizadas e sempre consideradas em todos os re-
cm-nascidos portadores de doenas potencialmente dolorosas e/
ou submetidos a procedimentos invasivos, cirrgicos ou no.
Unitermos: ANALGSICOS, Opiides: morfina, fentanil, sufentanil,
alfentanil, remifentanil; ANALGSICOS, No-opiides: paracetamol,
dipirona, indometacina; ANESTSICOS: Local; DOR, Tratamento: no-
farmacolgico, farmacolgico; SEDAO: recm-nascido.
SUMMARY
Silva YP, Gomez RS, Mximo TA, Silva ACS Sedation and Anal-
gesia in Neonatology.
BACKGROUND AND OBJECTIVES: The study of pain in
neonatology is important because pain and stress mean suffering
and discomfort for newborns and, despite it, very little has been
done to minimize them. In this revision we discuss: prevention of
pain, non-pharmacological and pharmacological treatment, and
sedation in newborns.
CONTENTS: Several non-pharmacological measures can be taken
to prevent pain in Neonatal Intensive Care Units, and to humanize
and reduce the stress on the environment for patients and their
families. Pain treatment in the newborn consists of non-pharma-
cological (non-nutritive suckling, glucose) and pharmacological
(non-opioid analgesics, opioids, and local anesthetics) measures.
Sedation in the newborn is achieved with drugs that decrease
activity, anxiety, and agitation of the patient, and that could lead to
amnesia of painful and non-painful events. Sedation can be accom-
plished with chloral hydrate, barbiturates, propofol, and benzo-
diazepines.
CONCLUSIONS: Prevention of pain and the indication of analgesia
should be individualized and always considered in every newborn
with potentially painful disorders and/or undergoing invasive
procedures, surgical or not.
Key Words: ANALGESICS, Opioids: morphine, fentanyl, sufentanil,
alfentanil, remifentanil; ANALGESICS: Non-opioids: paracetamol,
dipyrone, indomethacin; ANESTHETICS: Local; PAIN, Treatment: non-
pharmacologic, pharmacologic; SEDATION: newborn.
INTRODUO
O alvio da dor e o conforto do paciente so misses mdicas
primordiais, envolvendo questes ticas e humanitrias do
exerccio da medicina e, assim, a dor do recm-nascido
tambm deve ser reconhecida e tratada
1,2
. A importncia do
estudo da dor em neonatologia deve-se ao fato de que a
sensao de dor e estresse significa sofrimento e descon-
forto para os recm-nascidos e, apesar desse conhecimen-
to, pouco tem sido feito para minimiz-los
3
.
A indicao de analgesia deve ser individualizada e sempre
considerada em todos os recm-nascidos portadores de
doenas potencialmente dolorosas e/ou submetidos a pro-
cedimentos invasivos, cirrgicos ou no. Atualmente, h con-
senso mundial sobre a importncia do controle da dor no
recm-nascido, porm vrios trabalhos evidenciam que
mdicos e enfermeiros mostram-se quase sempre incapa-
zes de identificar e tratar a dor do recm-nascido e do lac-
Sedao e Analgesia em Neonatologia*
Sedation and Analgesia in Neonatology
Yerkes Pereira e Silva
1
, Renato Santiago Gomez, TSA
2
,

Thadeu Alves Mximo
3
, Ana Cristina Simes e Silva
4
*Recebido do (Received from) Hospital Life Center e Faculdade de Medi-
cina da Universidade Federal de Minas Gerais (FM/UFMG), Belo Horizonte,
MG
1. Anestesiologista e Neonatologista do Hospital Life Center, Belo Horizonte,
MG
2. Professor Adjunto do Departamento de Cirurgia da FM/UFMG
3. Aluno de Graduao da FM/UFMG
4. Professora Adjunto do Departamento de Pediatria da FM/UFMG
Apresentado (Submitted) em 12 de julho de 2006
Aceito (Accepted) para publicao em 25 de junho de 2007
Endereo para correspondncia (Correspondence to):
Yerkes Pereira e Silva
Rua Santa Rita Duro, 865, Apto. 903, Funcionrios
30315-560 Belo Horizonte, MG
E-mail: yerkesps@uol.com.br ou yerkes@lifec.com.br
Sociedade Brasileira de Anestesiologia, 2007
576 Revista Brasileira de Anestesiologia
Vol. 57, N
o
5, Setembro-Outubro, 2007
SILVA, GOMEZ, MXIMO E COL.
tente que no se queixa verbalmente
4-7
. Assim, a falta da
verbalizao um dos maiores obstculos ao diagnstico
e tratamento adequado da dor em neonatos na unidade de
terapia intensiva
1
.
O consenso de especialistas da rea, realizado em 2001,
definiu alguns princpios gerais da sedao e analgesia em
neonatologia
8
: a) a dor no recm-nascido , em geral, no-
reconhecida e subtratada, devido falta de condies ver-
bais da criana em express-la; b) se um procedimento
doloroso nos adultos ele dever ser considerado doloroso em
recm-nascidos e em prematuros; c) comparados com cri-
anas maiores e adultos, os recm-nascidos, sobretudo os
prematuros, podem apresentar sensibilidade maior dor e
serem mais suscetveis aos efeitos de longo prazo da
estimulao nociceptiva; d) o tratamento adequado da dor
em recm-nascidos est associado diminuio de mor-
bidade e da mortalidade; e) o uso apropriado de interven-
es ambientais, comportamentais e farmacolgicas pode
prevenir, reduzir ou eliminar a dor do recm-nascido em
muitas situaes clnicas; f) a sedao no proporciona al-
vio da dor e pode mascarar a resposta do recm-nascido ao
estmulo doloroso; g) os profissionais de sade tm a res-
ponsabilidade de avaliao, preveno e manuseio da dor
em recm-nascidos.
PREVENO DA DOR NO RECM-NASCIDO
Vrias so as medidas comportamentais (no-farmacol-
gicas) que podem ser realizadas com o intuito de prevenir
a dor nas Unidades de Terapia Intensiva Neonatal e tam-
bm para tornar o ambiente mais humanizado e menos es-
tressante para os pacientes e seus familiares: controlar a
incidncia de luzes fortes sobre o recm-nascido; diminuir
o rudo a sua volta (alarmes e conversas); racionalizar a mani-
pulao do paciente (preservar perodos livres para o sono
e evitar mltiplas coletas de sangue que devem ser agrupa-
das), utilizando protocolos de manipulao mnima; estimular
o uso de cateteres centrais; diminuir a quantidade de espa-
radrapos e outras fitas adesivas sobre a pele; posicionar de
forma adequada o tubo traqueal evitando sua trao ou mo-
vimentao desnecessria; cuidados com o material de
monitorao (observar a adaptao do manguito de presso
no-invasiva reduzindo os intervalos de medio, dos ele-
trodos do eletrocardiograma, dos sensores do oxmetro de
pulso promovendo seu rodzio); e sempre que possvel prover
o contato pele a pele entre os pais e o recm-nascido
9-10
.
TRATAMENTO DA DOR NO RECM-NASCIDO
Tratamento No-Farmacolgico
Uso de Suco No-Nutritiva
Pode ser utilizada em pequenos procedimentos. Embora
haja controvrsias a respeito do uso da chupeta em unida-
des neonatais devido a sua associao a um possvel de-
sestmulo ao aleitamento materno, a suco no-nutritiva,
em pacientes prematuros e muito manipulados, parece ser
de grande utilidade na organizao neurolgica e emocio-
nal do recm-nascido aps o estmulo agressor, diminuindo
as repercusses fisiolgicas e comportamentais
1,10
. Assim,
acredita-se que o seu uso deva ser estimulado de maneira
seletiva em populaes especficas de recm-nascidos.
Constitui-se em medida coadjuvante para o tratamento da
dor do recm-nascido, parecendo no apresentar proprie-
dades analgsicas intrnsecas
11
.
Soluo Glicosada
Nos ltimos anos, vem-se discutindo a utilizao da gua
com acar como analgsico
12
. Demonstrou-se, em modelos
animais, que o efeito analgsico da glicose pode ser rever-
tido com antagonistas de opiides, o que sugere um meca-
nismo de ao envolvendo a liberao de endorfinas
13
. A
reviso do Cochrane Group
14
mostra reduo significativa
dos indicadores de dor quando a glicose foi usada como
analgsico em recm-nascidos prematuros e de termo sub-
metidos coleta de sangue. O efeito mais consistente a
reduo do tempo total de choro. Poucos trabalhos conside-
ram efeitos adversos e ressaltam que esses so mnimos,
como a diminuio temporria de saturao da hemoglobina
pelo oxignio. No existe um consenso sobre a dose adequa-
da de glicose a ser usada (0,012 a 0,12 g) e doses repetidas
parecem ser mais eficazes que uma dose nica. Alm dis-
so, parece haver sinergismo entre o uso de chupetas (suco
no-nutritiva) com a glicose
15
. Assim, possvel recomen-
dar o emprego clnico de solues glicosadas por via oral,
cerca de um a dois minutos antes de pequenos procedimen-
tos, como punes capilares, venosas ou arteriais.
Tratamento Farmacolgico
Analgsicos No-Opiides
Antiinflamatrios no-hormonais so os principais medica-
mentos do grupo. Esses frmacos agem inibindo a ci-
cloxigenase, diminuindo a sntese de prostaglandinas e,
conseqentemente, o processo inflamatrio
16
. So indica-
dos para dor leve ou como adjuvante no tratamento da dor
moderada e intensa ou quando a dor est associada a al-
gum processo inflamatrio.
Paracetamol
O paracetamol um medicamento seguro para uso no pe-
rodo neonatal. O incio da ao analgsica lento, cerca de
uma hora, sendo pouco efetivo em processos dolorosos in-
tensos
1
. A dose preconizada em neonatologia de 10 a 15
mg.kg
-1
em recm-nascidos de termo e 10 mg.kg
-1
em pre-
maturos; com intervalo de seis horas no devendo exceder
cinco doses do frmaco ao dia
1
. Deve ser administrado por
via oral uma vez que o paracetamol venoso no est dispo-
Revista Brasileira de Anestesiologia 577
Vol. 57, N
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SEDAO E ANALGESIA EM NEONATOLOGIA
nvel no Brasil. Ele est indicado no tratamento de dor com
intensidade leve e moderada, til como coadjuvante na
analgesia ps-operatria de recm-nascidos, pois no in-
terfere na agregao plaquetria nem induz irritao gstri-
ca
17
. Apresenta baixa hepatotoxicidade em recm-nascidos,
uma vez que as vias enzimticas hepticas responsveis
pela produo do metablito txico esto imaturas. O
frmaco est contra-indicado em recm-nascidos portado-
res de deficincia de glicose-6-fosfato-desidrogenase
1
.
Dipirona
Em decorrncia da falta de estudos clnicos e farmaco-
lgicos que respaldem seu uso, o frmaco no recomen-
dado nessa faixa etria
1
. Porm, a grande experincia com
seu uso no Brasil demonstra a segurana e eficcia anal-
gsica e antitrmica, inclusive no perodo neonatal, sem in-
cidncia aumentada de efeitos colaterais comprovados
10
. A
dose de 10 a 15 mg.kg
-1
a cada seis horas, podendo ser
administrada por via oral ou venosa
10
.
Indometacina
Seu uso est indicado em recm-nascidos para tratamen-
to da persistncia do canal arterial, no havendo estudos
que justifiquem seu emprego como analgsico no perodo
neonatal
16
.
Analgsicos Opiides
Constituem a mais importante arma para o tratamento da
dor em recm-nascidos gravemente enfermos. Os analg-
sicos opiides ligam-se aos trs maiores grupos de recep-
tores de membrana na medula espinal e no crtex: , e .
O estmulo aos receptores inibe a transmisso do estmu-
lo nociceptivo aos centros superiores de processamento. Os
opiides inibem a aferncia da dor na medula espinal e ati-
vam as vias descendentes inibitrias
18
. Devido ao em
outros receptores opiides, podem causar depresso res-
piratria, sedao, leo, reteno urinria, nusea, vmitos
e dependncia fsica
18,19
. A via oral de mais fcil adminis-
trao e proporciona nveis sricos constantes, mas no
apropriada para pacientes gravemente enfermos ou aps
grandes procedimentos cirrgicos. Nesse caso, a via veno-
sa deve ser usada ponderando-se o uso em infuso cont-
nua a fim de se evitar flutuaes nos nveis sricos do
frmaco. Deve-se evitar a aplicao intramuscular porque
ela causa dor, mas esses agentes podem ainda ser usa-
dos pelas vias transdrmica, transmucosa, retal, subcut-
nea, intratecal e peridural
1
.
Morfina
o padro dentre os agonistas do receptor , sendo potente
analgsico e sedativo, alm de apresentar baixo custo
18
. O
incio de ao varia de trs a cinco minutos com T
1/2
Ke0
(meia vida de equilbrio entre o plasma e o local de ao
crebro) de 30 minutos
20
. Estudos de farmacocintica aps
doses em bolus mostraram que em recm-nascidos prema-
turos, menores e maiores de 30 semanas de gestao, ob-
serva-se meia-vida de eliminao maior e depurao
diminuda nos pacientes mais prematuros, apesar de vari-
aes individuais importantes terem sido notadas nos dois
grupos
21
. Avaliando-se a meia-vida de eliminao, a depu-
rao e o metabolismo da morfina em recm-nascidos de
24 a 40 semanas, de idade gestacional do primeiro ao se-
xagsimo dia de vida, notou-se um espectro amplo de varia-
o nos parmetros farmacocinticos, e a meia-vida tende
a diminuir e a depurao a aumentar com o aumento da ida-
de gestacional
21,22
. Todos os recm-nascidos excretaram
mais de 20% da morfina de forma no-metabolizada e um
tero deles no metabolizou a morfina em seus metablitos
primrios
22
. Considerando-se o uso da morfina em infuso
contnua em recm-nascidos, os estudos de farmacocin-
tica mostraram tambm aumento do clearance e da meia-
vida de eliminao se comparados com os pacientes
adultos
23
. O aumento do clearance da morfina nos primei-
ros seis meses de vida se deve mais elevao do poder
de glicuronidao do que s mudanas na ligao a prote-
nas ou percentagem de sulfatao. Assim, a concentrao
plasmtica da morfina mostrou-se duas a trs vezes maior
em recm-nascidos de termo e quatro vezes maior no pre-
maturo do que em crianas maiores. Alm disso, o nvel
plasmtico do frmaco tende a aumentar mesmo depois
que ele tenha sido descontinuado devido recirculao
entero-heptica
24
.
Poucos investigadores tm tentado caracterizar a concen-
trao mnima de morfina necessria para analgesia em
recm-nascidos. Chay e col. mostraram que uma concen-
trao de morfina de 125 ng.mL
-1
era necessria para pro-
duzir sedao adequada em 50% dos recm-nascidos
estudados (de termo e prematuros)
25
. Como concentraes
de 4 a 65 ng.mL
-1
so consideradas como analgsicas em
crianas maiores, uma explicao para a discrepncia en-
tre as necessidades aumentadas de morfina no perodo
neonatal so as baixas concentraes do metablito morfina-
6-glicurondeo (M6G) que so produzidas e a imaturidade do
sistema receptor opiide (diminuio da concentrao de
receptores e/ou da afinidade pelos receptores) no encfalo
do recm-nascido
18
. Alm dos efeitos colaterais comuns a
todos os opiides (depresso respiratria, nuseas, vmi-
tos e reteno urinria), a morfina desencadeia liberao de
histamina, podendo provocar broncoespasmo em recm-
nascidos portadores de doena pulmonar crnica. A libera-
o de histamina e a inibio do tnus adrenrgico podem
levar hipotenso arterial, sobretudo em recm-nascidos
hipovolmicos. A tolerncia e a sndrome de abstinncia po-
dem ser observadas dependendo do tempo de utilizao e
da estratgia empregada para a suspenso do frmaco
18
.
As doses recomendadas para o perodo neonatal so
1
:
578 Revista Brasileira de Anestesiologia
Vol. 57, N
o
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SILVA, GOMEZ, MXIMO E COL.
administrao intermitente de 0,05 a 0,20 mg.kg
-1
por
dose at a cada quatro horas por via venosa;
administrao contnua para recm-nascidos de termo
de 5 a 20 g.kg
-1
.h
-1
e para recm-nascidos prematuros
de 2 a 10 g.kg
-1
.h
-1
.
Fentanil
muito usado em neonatologia devido sua capacidade de
prover rpida analgesia com estabilidade hemodinmica
16
.
Apresenta incio de ao mais rpido e durao mais curta
(menos de duas horas) comparando-se com a morfina,
sendo seu T
1/2
Ke0 de 6,4 minutos e meia-vida contexto-sen-
sitiva aps quatro horas de infuso de 260 minutos
20,23
.
Redistribui-se dos receptores opiides para outros tecidos,
como msculos, estmago e gordura. Assim, aumentos
transitrios da concentrao plasmtica em virtude da
redistribuio do frmaco a partir desses tecidos podem
ocorrer. Apresenta alto metabolismo heptico e o clearance
primariamente dependente do fluxo heptico
18
. A farma-
cocintica pode estar alterada na presena de aumento da
presso intra-abdominal, pois nessas situaes observa-se
diminuio do fluxo heptico e do dbito cardaco, permitin-
do o acmulo do fentanil em locais de m perfuso e recir-
culao posteriormente
24
. Doses altas (acima de 5 g.kg
-1
),
quando injetadas rapidamente, podem levar rigidez mus-
cular, em especial da caixa torcica, dificultando a ventilao e
induzindo laringoespasmo em recm-nascidos
26
. As doses
recomendadas para o perodo neonatal so
10
:
administrao intermitente de 1 a 4 g.kg
-1
por dose, a
cada 2 a 4 horas, por via venosa;
administrao contnua em recm-nascidos de termo de
0,5 a 3 g.kg
-1
.h
-1
por via venosa e para recm-nascidos
prematuros de 0,5 a 2 g.kg
-1
.h
-1
por via venosa. A des-
vantagem da infuso contnua o aparecimento rpido
do efeito de tolerncia, sendo necessrias doses cres-
centes do frmaco para se obter o efeito analgsico de-
sejado
1
.
Sufentanil
Opiide sinttico, agonista potente do receptor apresen-
tando meia-vida curta. Sua meia-vida contexto sensitiva
aps quatro horas de infuso de 30 min, apresentando
meia-vida de eliminao de 2,2 a 4,6 horas e equilbrio entre
o plasma e o encfalo de 6,2 minutos
23
. Como o sufentanil
altamente ligado glicoprotena cida alfa-1, a ligao pro-
tica do frmaco dependente dos nveis sricos dessa
protena. Como a concentrao plasmtica dessa protena
diminuda em recm-nascidos, o frmaco na forma livre
muito maior nesses pacientes do que em crianas maio-
res
27
. Os estudos de farmacocintica do sufentanil mostram
resultados semelhantes aos do fentanil, como clearance
diminudo e meia-vida de eliminao aumentada nos recm-
nascidos prematuros, comparados com os recm-nascidos
de termo e crianas maiores
24
. A dose de 0,5 a 1,5 g.kg
-1
por dose. A injeo rpida pode levar a rigidez torcica, v-
mitos e convulses
10
.
Alfentanil
Opiide sinttico derivado do fentanil apresentando um quar-
to de sua potncia. O incio de ao aps infuso venosa
imediato e o pico do efeito acontece em um minuto com um
T
1/2
Ke0 de 0,9 a 1,4 minuto
20,23
. A meia-vida contexto sensi-
tiva aps quatro horas de infuso de 60 minutos e a du-
rao de ao de cerca de um tero da do fentanil
20,23
. De
maneira geral, o clearance do alfentanil est diminudo nos
recm-nascidos e sua meia-vida prolongada
18,20
. O volu-
me de distribuio pode estar aumentado por causa da
maior percentagem de gua corporal e/ou pela diminuio
da ligao s protenas
18,20
.
Remifentanil
Opiide sinttico, agonista dos receptores , possuindo a
mesma potncia do fentanil. Apresenta todas as caracte-
rsticas farmacodinmicas de sua classe (analgesia, esta-
bilidade hemodinmica, depresso respiratria e rigidez
muscular), porm apresenta perfil farmacocintico nico
devido estrutura ster que o torna suscetvel ao rpido me-
tabolismo por esterases plasmticas e teciduais no-espe-
cficas e que redunda em sua ao ultracurta
28
. A meia-vida
contexto-sensitiva aps quatro horas de infuso de apenas
quatro minutos, fazendo com que o trmino da ao inde-
penda do tempo de infuso
23
. Assim, a recuperao dos
efeitos do remifentanil ocorre rapidamente (dentro de cinco
a dez minutos) e um nvel fixo de concentrao atingido
aps cinco a dez minutos de uma mudana na velocidade
de infuso. Durante a meia-vida de distribuio (0,9 minu-
to) e eliminao (6,3 minutos) estimado que 99,8% do
remifentanil seja eliminado. Portanto, ao contrrio de outros
anlogos do fentanil a durao de ao do remifentanil no
aumenta com a administrao prolongada
23
. Alm disso, a
farmacocintica no se altera na presena de insuficincia
heptica ou renal desde que o metabolismo pelas esterases
no-especficas esteja preservado
29
. Os efeitos farmacodi-
nmicos seguem de perto as concentraes sangneas,
permitindo correlao direta entre dose, nveis sangneos
e a resposta
30,31
. Podem ocorrer alteraes hemodinmicas
(hipotenso arterial e bradicardia); respiratrias (depresso
respiratria); rigidez muscular relacionada com a dose e a
velocidade de infuso de um bolus. Por outro lado, no se
observa liberao de histamina em doses convencionais
23
.
Samartino e col. avaliaram a eficcia e segurana do uso con-
tnuo por via venosa de remifentanil em recm-nascido pre-
maturo que seriam submetidos laserterapia para
tratamento da retinopatia da prematuridade. A recuperao
rpida e o retorno ao status pr-operatrio, associado au-
sncia de efeitos colaterais e aos excelentes nveis de anal-
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SEDAO E ANALGESIA EM NEONATOLOGIA
gesia e anestesia obtidos confirmaram a eficcia e a segu-
rana da administrao contnua de remifentanil em recm-
nascidos prematuros e do substrato escolha desse
opiide
32
.
As doses variam de acordo com o objetivo desejado
23
e,
em recm-nascidos a dose inicial em bolus para intuba-
o varia de 1 a 3 g.kg
-1
e para infuso contnua de 0,1 a
5 g.kg
-1
.min
-1

33
.
Outros Opiides
O tramadol e a codena tambm so utilizados para o trata-
mento da dor moderada. O tramadol tem 1/10 da potncia
da morfina e seu mecanismo de ao inclui caractersticas
de opiides e no-opiides. Estimula a liberao de
serotonina nas terminaes nervosas e inibe a recaptao
tanto de serotonina quanto de noradrenalina
34
. Causa pou-
ca depresso respiratria e constipao intestinal, alm de
ter um menor potencial para desenvolver tolerncia e de-
pendncia
34
. Apesar das vantagens potenciais do emprego,
os estudos com a aplicao desse frmaco em crianas
so escassos e por isso seu uso em neonatologia ainda
limitado. A meperidina, por outro lado, est praticamente
proscrita para o tratamento da dor, sobretudo em decorrn-
cia da formao de metablitos txicos (normeperidina) que
podem diminuir o limiar convulsivo
10
.
Anestsicos Locais
O EMLA

(mistura euttica de lidocana e prilocana) produz


anestesia em pele intacta, seguro no recm-nascido quan-
do aplicado isoladamente em um nico procedimento e
eficaz para reduzir a dor causada por circunciso, punes
arteriais, venosas e puno lombar
35
. Como desvantagens,
pode-se citar a latncia de cerca de 60 minutos; vasocons-
trio que dificulta a puno venosa e o risco de metaemoglo-
binemia
35
. O ELA-Max creme um anestsico local tambm
para uso tpico sendo seu incio de ao em cerca de 30
minutos. Causa menos vasoconstrio do que o EMLA
36
.
A infiltrao local de anestsico local (lidocana) indicada
na puno lombar, insero de cateter central, drenagem
torcica e, eventualmente, na puno arterial. O incio da
ao quase imediato e a durao do efeito, de 30 a 60 mi-
nutos aps a infiltrao. Deve-se sempre respeitar a dose
mxima de 5 mg.kg
-1

10
.
SEDAO NO RECM-NASCIDO
A sedao em recm-nascidos produzida por frmacos
que agem diminuindo a atividade, ansiedade e a agitao
do paciente, podendo levar amnsia de eventos dolorosos
ou no-dolorosos
1
. No entanto, tais medicamentos em ge-
ral no reduzem a dor e, pelo contrrio, poderiam potencia-
liz-la, apesar de alguns analgsicos opiides como a
morfina tambm terem a capacidade de sedao
37
. Antes
da prescrio de qualquer sedativo, todas as possveis cau-
sas de agitao devem ser pesquisadas e tratadas de
forma adequada, como dor, fome, hipoxemia, hipotermia, hi-
pertermia, leses inflamatrias, inadequao dos parme-
tros de ventilao mecnica, entre outras. As principais
indicaes de sedao no recm-nascido so a realizao
de procedimentos diagnsticos que exigem algum grau de
imobilidade (tomografia computadorizada e ressonncia
magntica); suporte ventilatrio agressivo em recm-nasci-
dos agitados com hipoxemia persistente e ps-operatrio
de intervenes cirrgicas como as de fechamento de pa-
rede abdominal
1,38
. Algumas escalas so mais apropriadas
para avaliar o grau de sedao do paciente nessa faixa et-
ria, como a escala de COMFORT
39
.
Hidrato de Cloral
O hidrato de cloral sedativo e hipntico, sendo utilizado
para procedimentos diagnsticos ou teraputicos de curta
durao. Seu mecanismo de ao ainda no est bem elu-
cidado e sua eliminao dependente da idade, sendo lenta
no recm-nascido
38
. Pode-se observar ainda, em prematuros,
efeito residual do frmaco at 64 horas aps a sua admi-
nistrao. Seu metablito ativo, o tricloroetanol, mutag-
nico e pode causar leso cromossmica. Tambm pode
levar a hiperbilirrubinemia direta e indireta e acidose meta-
blica em recm-nascidos. Pode causar irritao gstrica,
com aparecimento de nuseas, vmitos e diarria, alucina-
es, cefalia, depresso residual do sistema nervoso com
sonolncia, depresso miocrdica com disritmia cardaca,
obstruo de vias areas e depresso respiratria. Por cau-
sa desses efeitos ele no recomendado para uso no pe-
rodo neonatal
1,40
.
Barbitricos
Os barbitricos so potentes depressores do sistema ner-
voso central e tm efeito anticonvulsivante
40
. No apresen-
tam atividade analgsica intrnseca e podem at intensificar
a sensao de dor
37
. O nvel de depresso da atividade neu-
rolgica depende da farmacocintica do agente, da dose, da
via de administrao, da condio clnica e do uso simult-
neo de outros frmacos
1
.
Propofol
O propofol um potente depressor do sistema nervoso cen-
tral, cuja ao rapidamente reversvel, sem deixar sedao
residual
41
. O incio da ao ocorre, em geral, em cerca de um
a trs minutos aps a infuso do frmaco, durando cerca de
15 a 20 minutos. O medicamento possui atividade antie-
mtica, sendo indicado para sedao durante procedimen-
tos diagnsticos, teraputicos ou para induo de anestesia
geral em crianas maiores e adultos. Causa depresso res-
piratria e hipotenso arterial, potencializadas pelo uso con-
580 Revista Brasileira de Anestesiologia
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SILVA, GOMEZ, MXIMO E COL.
comitante de opiides, cetamina ou xido nitroso. A segu-
rana para o uso na populao neonatal ainda motivo de
estudo
42
. A sndrome de infuso do propofol uma preocu-
pao quando o frmaco usado em infuso contnua por
longos perodos de tempo (mais de 24 horas) e em altas
doses (mais de 75 g.kg
-1
.min
-1
)
41,43
.
Benzodiazepnicos
Os benzodiazepnicos so os frmacos mais empregados
para sedao, ansilise e induo de amnsia. No apre-
sentam qualquer atividade analgsica e podem, inclusive,
exercer efeito antianalgsico
44
. Podem levar ao aparecimen-
to de depresso respiratria, obstruo de vias areas,
hipotenso arterial e excitao paradoxal e os seus efeitos
so potencializados pelos opiides
40
.
Diazepam
um potente sedativo ansioltico com ao anticonvul-
sivante. No entanto, a tolerncia ao efeito sedativo rpida.
Interfere na ligao albumina-bilirrubina aumentando a
quantidade de bilirrubina livre circulante. Raramente utili-
zado em Unidades de Terapia Intensiva Neonatal, a no ser
como dose isolada para promover sedao de durao pro-
longada, na dose de 0,05 a 0,2 mg.kg
-1
por via venosa, apre-
sentando incio de ao em dois a trs minutos e durao
de duas a seis horas
45
.
Midazolam
um benzodiazepnico com boa atividade sedativa hipnti-
ca, que apresenta potncia duas a quatro vezes maior do
que o diazepam, tem rpido incio de ao e pode causar
amnsia
46
. Apresenta tempo de equilbrio plasma-encfalo
(T
1/2
Ke0) entre 0,9 e 5,6 minutos, sendo de 2,7 minutos o pe-
rodo de tempo necessrio para que 87,5% desse equilbrio
ocorra
46
. Em recm-nascidos gravemente enfermos a meia-
vida de eliminao pode estar muito prolongada (6,5 a 12
horas) assim como seu clearance diminudo (0,07 a 0,12
L.h
-1
.kg
-1
). Pode ainda causar depresso respiratria e
hipotenso arterial, potencializadas pelo uso concomitante
de opiides, alm de poder levar dependncia fsica se
usado de forma contnua por mais de 48 horas
1
. Apesar de
ser um sedativo eficaz comparado com o placebo, ainda
no se podem tirar concluses definitivas sobre sua efeti-
vidade e segurana no recm-nascido
47,48
. Quando usado
por via venosa intermitente, as doses em bolus so de 0,05
a 0,20 mg.kg
-1
, administrado a cada duas a quatro horas,
com incio de ao de um a trs minutos, pico de ao de
trs a cinco minutos e durao de uma a duas horas. Se
usado por via venosa contnua, em geral as doses variam
de 1 a 6 g.kg
-1
.min
-1

1,10
. A via intranasal tem sido desacon-
selhada, devido ao risco de toxicidade ao sistema nervoso
central ao ser absorvido, entrando em contato direto com o
nervo olfatrio via placa crivosa
49
. Um possvel efeito cola-
teral o aparecimento de convulses quando feita a ad-
ministrao rpida e em doses elevadas
50
. Pode ainda
causar diminuio do fluxo sangneo para artria cerebral
mdia em recm-nascidos prematuros
51,52
, alm de efeitos
neurolgicos transitrios (hipertonia, hipotonia, movimentos
coricos, movimentos discinticos, mioclonia e atividade
epileptiforme).
No h dados suficientes para promover o uso de infuso
contnua de midazolam como sedativo para recm-nascidos
em Unidades de Terapia Intensiva Neonatal. Apesar de o
midazolam ser usado muitas vezes de forma indiscrimi-
nada, de modo isolado ou em associao ao fentanil nas
Unidades de Terapia Intensiva Neonatais, foi demonstrado
que o seu uso em infuso contnua em recm-nascidos
prematuros est associado a efeitos adversos graves, como
morte, leucomalcia e hemorragia periintraventricular
48
.
Antagonistas de Benzodiazepnicos e de Opiides
A disponibilidade de antagonistas especficos para os ben-
zodiazepnicos e para os opiides aumentou a segurana
da sedao para procedimentos, j que a depresso res-
piratria pode ser revertida com rapidez
10
.
A naloxona um antagonista no-seletivo de opiides, ex-
tremamente potente e que deve ser usada na dose de 1 a
4 g.kg
-1
para reverter depresso respiratria causada pelo
uso dos opiides. Como tem meia-vida curta (meia-vida de
eliminao de 60 minutos) a maioria dos pacientes pode
necessitar de doses repetidas, infuso contnua ou depsito
intramuscular, alm de monitorao, para evitar efeito rebote
do quadro de sedao e depresso respiratria. um an-
tagonista no apenas dos efeitos adversos, como depres-
so respiratria, rigidez muscular e efeitos gastrintestinais,
mas tambm da sedao e da analgesia
23
.
O flumazenil um antagonista puro dos benzodiazepnicos
que inibe de forma competitiva o complexo receptor GABA-
diazepnico no sistema nervoso central. utilizado para re-
verter os efeitos sedativos dos benzodiazepnicos aps
sedao ou intoxicao. Tem durao de ao mais curta do
que a maioria dos benzodiazepnicos. O antagonismo ini-
cia-se um a dois minutos aps a dose por via venosa, com
pico em seis a dez minutos. A dose utilizada varia de 4 a
20 g.kg
-1
e, como efeitos colaterais podem ocorrer nuseas,
vmitos, zumbidos, cefalia, convulses, ansiedade e labi-
lidade emocional
1,53
.
Sndrome de Abstinncia no Recm-Nascido
Se durante a retirada ou aps a suspenso dos frmacos
utilizados para sedao e analgesia surgirem sinais e sin-
tomas de abstinncia, como taquicardia, agitao, sudore-
se, nusea, vmitos, diarria, distrbios do sono e mesmo
rebote da dor, deve-se considerar a possibilidade de iniciar
o tratamento de abstinncia que envolve vrias opes te-
Revista Brasileira de Anestesiologia 581
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o
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SEDATION AND ANALGESIA IN NEONATOLOGY
raputicas, como a metadona, o fenobarbital, a clonidina, o
lorazepam ou associaes entre eles
8,10
. A monitorao dos
sintomas de abstinncia pode ser feita por meio de escala
prpria, como a escala de Finnegan
54
.
CONCLUSO
A morfina vem sendo preconizada como frmaco de esco-
lha segundo os consensos mundiais de sedao e anal-
gesia em recm-nascidos. Porm, a morfina no sempre
a melhor opo para analgesia e sedao de recm-nas-
cidos prematuros uma vez que tambm nessas crianas
(prematuros de 27 a 29 semanas de idade gestacional) foi
observada uma diferena estatstica significativa de hemor-
ragia peri-intraventricular grave nos pacientes submetidos
a infuso contnua de morfina
55
. Alm disso, a morfina
apresenta o inconveniente de ter seu metabolismo depen-
dente da funo renal e heptica do recm-nascido, poden-
do manter grau de sedao residual que muitas vezes
implicada no retardo da extubao. Os estudos de farmaco-
cintica da morfina mostraram variabilidade considervel
em recm-nascidos de termo e tambm em prematuros, e
o clearance plasmtico da morfina est diminudo em re-
cm-nascidos prematuros
56,57
.
Assim, vrios estudos tm mostrado a segurana e efic-
cia do remifentanil na analgesia e anestesia de crianas e
recm-nascidos, assim como em recm-nascidos prema-
turos
32,33,58
. Como o remifentanil no apresenta efeito de
sedao residual aps sua suspenso, pode-se tornar uma
opo na sedao e analgesia de recm-nascidos prema-
turos
59,60
.
Sedation and Analgesia in Neonatology
Yerkes Pereira e Silva, M.D.; Renato Santiago Gomez, TSA,
M.D.;

Thadeu Alves Mximo, M.D.; Ana Cristina Simes e Sil-
va, M.D.
INTRODUCTION
Pain relief and the comfort of the patient are basic missions
of the physician, involving ethical and humanitarian issues
of the medical practice. Therefore, pain in the newborn should
also be recognized and treated
1,2
. The importance of the
study of pain in neonatology derives from the fact that pain
and stress mean suffering and discomfort for newborns and,
despite of this, very little has been done to minimize them
3
.
The indication of analgesia should be individualized and
always considered in every newborn with potentially painful
disorders and/or undergoing invasive procedures, surgical
or not. Currently, there is a consensus about the importance
of pain control in the newborn. However, several studies have
indicated that physicians and nurses are usually incapable
of identifying and treat pain in newborns and infants, who do
not complaint verbally
4-7
. Thus, the lack of verbalization is
one of the greatest obstacles for the diagnosis and proper
treatment of pain in newborns in the intensive care unit
1
.
In 2001, the specialists in the area defined some general
principles of sedation and analgesia in newborns
8
: a) pain
in the newborn is usually not recognized and, therefore, is
undertreated, due to the incapacity of the children to verbalize
it; b) if a procedure is painful in adults, it should be consi-
dered painful in newborns and premature neonates; c) com-
pared with older children and adults, newborns, especially
premature neonates, may have greater sensitivity to pain
and may be more susceptible to the long-term effects of
nociceptive stimulation; d) proper treatment of pain in new-
borns is associated with a reduction in morbidity and morta-
lity; e) the appropriate use of environmental, behavioral, and
pharmacological interventions can prevent, reduce, or eli-
minate pain in the newborn in many clinical situations; f)
sedation does not offer pain relief, and may mask the res-
ponse of the newborn to the painful stimulus; and g) health
care professionals are responsible for evaluating, preventing,
and managing pain in the newborn.
PREVENTION OF PAIN IN THE NEWBORN
Several behavioral measures (non-pharmacological) may be
undertaken to prevent pain in the Neonatal Intensive Care
Unit and to make the environment more humane and less
stressful for patients and their families, such as: control the
incidence of strong lights on the newborn; reduce the noise
around the baby (alarms and conversation); rationalize pa-
tient handling (preserving free periods for sleep and avoiding
several blood drawings, which should be made as a set),
using protocols for minimal handling; stimulate the use of
central catheters; decrease the amount of tape on the skin;
adequate positioning of the tracheal tube, avoiding traction
or unnecessary movement; care with monitoring devices (ob-
serve the adaptation of the blood pressure cuff, reducing the
number of measuring intervals; electrocardiogram electro-
des, and pulse oximetry sensors, alternating them); and,
whenever possible, to promote skin contact between the
newborn and its parents
9,10
.
TREATMENT OF PAIN IN THE NEWBORN
Non-Pharmacological Treatment
Use of Non-Nutritive Suckling
It can be used in small procedures. Although there are con-
troversies on the use of pacifiers in neonatal units due to the
possible association with decreased stimulation to maternal
breastfeeding, non-nutritive suckling in premature neonates
that are intensively handled seems to be of great value in
the neurological and emotional organization of the newborn
after the aggressor stimulus, decreasing physiological and
behavioral repercussions
1,10
. Thus, it is believed that its use
582 Revista Brasileira de Anestesiologia
Vol. 57, N
o
5, Setembro-Outubro, 2007
should be selectively stimulated in specific populations of
neonates. It constitutes an adjuvant measure in pain treat-
ment in the newborn, and it seems that it does not have
intrinsic analgesic properties
11
.
Glucose Solution
In the past few years the use of water with sugar as anal-
gesic has been discussed
12
. It has been demonstrate, in
animal models, that the analgesic effect of glucose can be
reversed by opioid antagonists, suggesting a mechanism of
action involving the release of endorphins
13
. The revision of
the Cochrane Group
14
shows a significant reduction in pain
indicators when glucose was used as an analgesic for blood
drawing in premature and term newborns. The most con-
sistent effect is the reduction in the total time of crying. Few
studies consider adverse effects, emphasizing that they are
minimal and include a temporary reduction in hemoglobin
saturation. A consensus on the adequate dose of glucose to
be used (0.012 to 0.12 g) is lacking, and it seems that repea-
ted doses are more effective than a single dose. Besides,
there seems to be a synergism between the use of pacifiers
(non-nutritive suckling) and glucose
15
. Therefore, it is pos-
sible to recommend the clinical use of oral glucose solutions
one to two minutes before small procedures, such as
capillary, venous, or arterial punctures.
Pharmacological Treatment
Non-Opioid Analgesics
Non-steroidal anti-inflammatories (NSAIDs) are the main group
of drugs. They inhibit the cyclooxigenase, decreasing the
synthesis of prostaglandins and, consequently, the inflam-
matory process
16
. They are indicated in the treatment of mild
pain, as adjuvant in the treatment of moderate and severe pain,
or when pain is associated with an inflammatory process.
Paracetamol
Paracetamol is a safe drug to be used in neonates. It has a
slow onset of analgesia, approximately one hour, having
little efficacy in severe pain
1
. The doses recommended in
neonatology are 10 to 15 mg.kg
-1
in newborns at term and
10 mg. kg
-1
in premature neonates, every 6 hours, and
should not exceed 5 doses a day
1
. It should be administe-
red orally, since intravenous paracetamol is not available in
Brazil. It is indicated in the treatment of mild to moderate pain,
it is useful as an adjuvant in postoperative analgesia in new-
borns because it does not interfere with platelet aggregation
and does not cause gastric irritation
17
. It has low hepatoto-
xicity in newborns, since enzymatic liver pathways respon-
sible for the production of the toxic metabolite are immature.
This drug is contra-indicated in newborns with deficiency of
glucose-6-phosphate dehydrogenase
1
.
Dypirone
Due to the lack of clinical and pharmacological studies that
validate its use, the drug is not recommended in this age
group
1
. However, the large experience with its use in Brazil
has demonstrated its safety and analgesic and antipyretic
efficacy, including in the neonatal period, without an increased
incidence of proven side effects
10
. The dose recommended
is 10 to 15 mg.kg
-1
every 6 hours, and it can be administered
orally or intravenously
10
.
Indomethacin
Its use is indicated in newborns for the treatment of patent
ductus arteriosus, but there are no studies that justify its use
as analgesic in the neonatal period
16
.
Opioid Analgesics
They constitute the most important weapon for the treatment
of pain in severely ill newborns. Opioid analgesics bind the
three major groups of membrane receptors in the spinal cord
and cortex: , , and . Stimulation of the receptors inhibits
the transmission of the nociceptive stimulus to upper pro-
cessing centers. Opioids inhibit afferent pain in the spinal
cord and activate descending inhibitory pathways. Due to
their action in other opioid receptors, they can cause respi-
ratory depression, sedation, ileus, urinary retention, nausea,
vomiting, and physical dependence
18,19
. The oral route is
easier to use and provides constant serum levels, but it is
not appropriate for severely ill patients or after large surge-
ries. In this case, the intravenous route should be used,
preferentially in continuous infusion to avoid fluctuations in
serum levels. Intramuscular administration should be avoi-
ded because it causes pain, but their administration can
also be transdermal, transmucous, rectal, subcutaneous,
intrathecal, and epidural
1
.
Morphine
Morphine is the standard among -receptors antagonists, it
is a potent analgesic and sedative, and has a low cost
18
. It
has an onset of action of 3 to 5 minutes and T
1/2
Ke0 (equili-
brium half-life between the plasma and its site of action
brain) of 30 minutes
20
. Pharmacokinetics studies after a
bolus dose showed that, in premature neonates, younger
than and older than 30 weeks of gestation, the elimination
half-life is greater and more premature patients have redu-
ced depuration, although both groups presented important
individual variations
21
. Evaluating the elimination half-life,
depuration, and metabolism of morphine in newborns with
24 to 40 weeks, from the first to the 60
th
day of life, a wide
variation in pharmacokinetic parameters was noted, but the
half-life tends to decrease and depuration to increase with
increased gestational age
21,22
. All newborns excreted more
SILVA, GOMEZ, MXIMO ET AL.
Revista Brasileira de Anestesiologia 583
Vol. 57, N
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5, Setembro-Outubro, 2007
than 20% of non-metabolized morphine and one third of them
did not metabolized morphine in its primary metabolites
22
.
Considering the use of morphine in continuous infusion in
newborns, pharmacokinetic studies also demonstrated an
increase in clearance and elimination half-life when compa-
red with adults
23
. The increase in morphine clearance in the
first six months of life is due to an increase in glucuronidation
rather than in changes in protein binding or percentage of
sulfatation. Thus, the plasma concentration of morphine is
twice to three times greater in newborns at term and four ti-
mes greater in premature neonates than in older children.
Besides, its plasma level tends to increase, even after it is
discontinued, due to the enterohepatic recirculation
24
.
Very few researchers tried to characterize the minimum con-
centration of morphine necessary for analgesia in newborns.
Chay et al. demonstrated that a concentration of morphine of
125 ng.mL
-1
was necessary to produce adequate sedation
in 50% of newborns studied (at term and premature)
25
. Since
concentrations of 4 to 65 ng.mL
-1
are considered analgesic
in older children, an explanation for the discrepancy in the
increased need of morphine in the neonatal period include
low concentration of the metabolite morphine-6-glucuronide
(M6G) produced and the immaturity of the opioid receptor
system (reduction in receptor concentration and/or affinity for
the receptors) in the brain of newborns
18
. Besides the colla-
teral effects common to all opioids (respiratory depression,
nausea, vomiting, and urinary retention), morphine triggers
the release of histamine, and can cause bronchospasm in
newborns with chronic pulmonary disease. The release of
histamine and the inhibition of the adrenergic tone could lead
to hypotension, especially in hypovolemic newborns. To-
lerance and withdrawal syndrome could be present, depen-
ding on the duration of morphine use and the strategy used
to discontinue the drug
18
.
The recommended doses for the neonatal period are
1
:
intermittent intravenous administration of 0.05 to 0.20
mg.kg
-1
per dose up to every 4 hours.
continuous administration for newborns at term of 5 to 20
g.kg
-1
.h
-1
and 2 to 10 g.kg
-1
.h
-1
in premature neonates.
Fentanyl
Fentanyl is commonly used in neonatology for its capacity of
providing fast analgesia with hemodynamic stability
16
. It has
faster onset of action and shorter duration (less than 2 hours)
than morphine, its T
1/2
Ke0 is 6.4 min, and a context sensitive
half-life of 260 min after four hours of infusion
20,23
. It is redis-
tributed from the opioid receptors to other tissues, such as
muscles, stomach, and adipose tissue. Thus, transitory in-
creases in plasma concentration can occur due to the redis-
tribution of the drug from those tissues. It has a large hepatic
metabolism and its clearance depends, primarily, on the liver
blood flow
18
. Its pharmacokinetics can be altered in the pre-
sence of increased intra-abdominal pressure because of
decreased hepatic blood flow and cardiac output, allowing its
accumulation in areas of poor perfusion and posterior recircu-
lation
24
. Fast administration of high doses (above 5 g.kg
-1
)
could cause muscle rigidity, especially in the thorax, hindering
ventilation and inducing laryngeal spasm in newborns
26
. The
recommended doses for the neonatal period are
10
:
intermittent intravenous administration of 1 to 4 g.kg
-1
every 2 to 4 hours.
continuous intravenous administration in newborns at
term of 0.5 to 3 g.kg
-1
.h
-1
and 0.5 to 2 g.kg
-1
.h
-1
in pre-
mature neonates. The downside of the continuous infu-
sion is the fast development of tolerance with the need of
increasing doses to achieve the desired analgesia
1
.
Sufentanil
Sufentanil is a synthetic opioid, potent agonist of receptors,
with a short half-life. It has a context sensitive half-life after
four hours of infusion of 30 minutes, an elimination half-life
of 2.2 to 4.6 hours, and a plasma-cerebral balance of 6.2
minutes
23
. Sufentanil is highly bound to alpha-1 acid glyco-
protein, and its binding depends on the serum level of this
protein. And since the plasma concentration of this protein is
reduced in newborns, the levels of free drug are significantly
higher in those patients than in older children
27
. Pharma-
cokinetic studies demonstrated results similar to fentanyl,
with decreased clearance and increased elimination half-life
in premature neonates when compared with newborns at
term and older children
24
. It is recommended the adminis-
tration of 0.5 to 1.5 g.kg
-1
per dose. Fast administration could
lead to thoracic rigidity, vomiting, and seizures
10
.
Alfentanil
It is a synthetic opioid derived from fentanyl, with one fourth
of its potency. The onset of action after venous infusion is
immediate, and the peak occurs in one minute, with T
1/2
Ke0
of 0.9 to 1.4 minutes
20,23
. It has a context sensitive half-life
after four hours of infusion of 60 minutes, and the duration
of action is approximately one third of that of fentanyl
20,23
. In
general, the clearance of alfentanil is decreased in new-
borns and its half-life is prolonged
18,20
. The volume of dis-
tribution might be increased due to the greater percentage
of body water and/or reduction in binding to proteins
18,20
.
Remifentanil
A synthetic opioid, agonist of receptors, it has the same po-
tency as fentanyl. It has all the pharmacodynamic properties
of its class (analgesia, hemodynamic stability, respiratory
depression, and muscle rigidity); however, its pharmaco-
kinetic profile is unique, due to the ester structure that makes
it susceptible to the fast metabolism by non-specific plasma
and tissue esterases, which is responsible for its ultra-short
action
28
. It has a context sensitive half-life after four hours of
infusion of four minutes, making the end of its action inde-
SEDATION AND ANALGESIA IN NEONATOLOGY
584 Revista Brasileira de Anestesiologia
Vol. 57, N
o
5, Setembro-Outubro, 2007
pendent of the duration of infusion
23
. Thus, the recovery from
the effects of remifentanil is fast (within 5 to 10 minutes), and
a fix concentration level is achieved five to 10minutes after a
change in the speed of infusion. It is estimated that 99.8%
of remifentanil is eliminated during the distribution (0.9 mi-
nute) and elimination (6.3 minutes) half-lives. Therefore,
unlike other fentanyl analogues, the duration of action of
remifentanil does not increase with prolonged administra-
tion
23
. Besides, its pharmacokinetics does not change in
the presence of liver or renal failure, unless the metabolism
by non-specific esterases is not preserved
29
. The pharmaco-
dynamic effects follow closely blood concentrations, allowing
the direct correlation among dose, blood levels, and res-
ponse
30,31
. Hemodynamic (hypotension and bradycardia),
and respiratory (respiratory depression) changes; and mus-
cular rigidity related to the dose and rate of infusion of a bolus
dose might occur. On the other hand, histamine release is
not seen with conventional doses
23
.
Samartino et al. evaluated the efficacy and safety of the
continuous intravenous use of remifentanil in premature
neonates undergoing laser therapy for the treatment of
retinopathy of prematurity. Fast recovery and the return to
preoperative status, associated with the absence of side
effects and the excellent levels of analgesia and anesthesia,
confirmed the efficacy and safety of the continuous admi-
nistration of remifentanil in premature neonates, reinforcing
the choice for this opioid
32
.
The doses vary according to the objective
23
and, in new-
borns, the initial dose varies from 1 to 3 g.kg
-1
for a bolus
and 0.1 to 5 g.kg
-1
.h
-1
for continuous infusion
33
.
Other Opioids
Tramadol and codeine are used for the treatment of mode-
rate pain. Tramadol has 1/10 of the potency of morphine and
its mechanism of action includes characteristics of opioids
and non-opioids. It stimulates the release of serotonin from
nerve endings and inhibits re-uptake of both serotonin and
noradrenaline
34
. It causes little respiratory depression and
constipation, besides having a lower potential to develop
tolerance and to cause addiction
34
. Despite the potential
advantages of its use, studies with this drug in children are
rare and for this reason, its use in neonatology is limited. On
the other hand, the use of meperidine for the treatment of
pain is practically proscribed, mainly due to the formation of
toxic metabolites (normeperidine) that can decrease the
seizure threshold
10
.
Local Anesthetics
EMLA

(an eutectic mixture of lidocaine and prilocaine) pro-


duces anesthesia on the skin, is safe to be used in new-
borns when applied isolatedly in one procedure, being
effective in reducing the pain caused by circumcision, and ar-
terial, venous, and lumbar punctures
35
. Its disadvantages
include the latency of approximately 60 minutes; vasocons-
triction, which hinders venous puncture; and the risk of me-
themoglobinemia
35
. ELA-Max cream is also a topic local
anesthetic, but it has an onset of action of 30 minutes. It cau-
ses less vasoconstriction than EMLA
36
.
Infiltration of a local anesthetic (lidocaine) is indicated in
lumbar punctures, introduction of central catheters, thoracic
drainage and, eventually, in arterial punctures. The onset of
action is almost immediate and lasts from 30 to 60 minutes.
The maximal dose of 5 mg.kg
-1 10
should always be observed.
SEDATION IN THE NEWBORN
Sedation in the newborn is accomplished with drugs that
decrease activity, anxiety, and agitation of the patient, and
could lead to amnesia of painful and non-painful events
1
.
However, those drugs usually do not reduce pain and, on the
contrary, could potentiate it, although some opioids, like mor-
phine, can also cause sedation
37
. Before prescribing a seda-
tive, all possible causes of agitation should be sought and
properly treated, such as pain, hunger, hypoxemia, hypother-
mia, hyperthermia, inflammatory lesions, and inadequacy of
mechanical ventilation parameters, among others. The main
indications of sedation in newborns include diagnostic proce-
dures that require some degree of immobility (CT and MRI);
aggressive ventilatory support in agitated newborns with
persistent hypoxemia, and postoperative management of sur-
geries, such as closure of the abdominal wall
1,38
. Some scales
are more appropriate than others to evaluate the degree of
sedation in this age group, such as the COMFORT scale
39
.
Chloral Hydrate
Chloral hydrate is a sedative and hypnotic agent, being used
in short diagnostic or therapeutic procedures. Its mechanism
of action has not been elucidated yet and its elimination de-
pends on the age of the patient, but is slow in newborns
38
.
In premature neonates one can observe residual effects of
the drug up to 64 hours after its administration. Its active
metabolite, trichloroethanol, is mutagenic and can cause
chromosomal damage. It can also increase blood levels of
direct and indirect bilirubin and metabolic acidosis in new-
borns. It can cause gastric irritation with nausea, vomiting,
diarrhea, and hallucinations, headache, and residual de-
pression of the central nervous system with somnolence,
myocardial depression with cardiac arrhythmias, obstruction
of the airways, and respiratory depression. For this reason,
its use is not recommended in the neonatal period
1,40
.
Barbiturates
Barbiturates are potent depressors of the central nervous
system and also have an anticonvulsant effect
40
. They do
not have intrinsic analgesic activity and can even intensify the
sensation of pain
37
. The level of depression of the neuro-
logical activity depends on the pharmacokinetics of the drug,
SILVA, GOMEZ, MXIMO ET AL.
Revista Brasileira de Anestesiologia 585
Vol. 57, N
o
5, Setembro-Outubro, 2007
route of administration, clinical condition, and simultaneous
use of other drugs
1
.
Propofol
Propofol is a potent depressor of the central nervous system,
whose action is rapidly reversible without residual sedation
41
.
In general, the onset of action occurs one to three minutes
after administration of the drug, lasting approximately 15 to
20 minutes. The drug has antiemetic activity, being indicated
for sedation during diagnostic or therapeutic procedures, or
for the induction of general anesthesia in older children and
adults. It causes respiratory depression and hypotension that
are potentiated by the concomitant administration of opioids,
ketamine, or nitrous oxide. The safety to be used in neonates
is still being studied
42
. Propofol infusion syndrome is a
concern when the drug is used in continuous infusion for a
long time (more than 24 hours) and in high doses (more than
75 g.kg
-1
.h
-1
)
41,43
.
Benzodiazepines
Benzodiazepines are the drugs used more often for seda-
tion, anxiety, and induction of amnesia. They do not have any
analgesic activity, and they can even have an anti-analgesic
effect
44
. They can cause respiratory depression, obstruction
of the airways, hypotension, and paradoxal excitation, and
their effects are potentiated by the opioids
40
.
Diazepam
It is a potent anti-anxiety sedative and anticonvulsant. Ho-
wever, patients develop tolerance to its sedative effect very
rapidly. It interferes with the binding of albumin-bilirubin,
increasing the amount of free circulating bilirubin. It is rarely
used in Neonatal Intensive Care Units, but for isolated do-
ses to promote prolonged sedation, in the dose of 0.05 to
0.2 mg.kg
-1
intravenously, with fast onset of action, of 2 to 3
minutes, lasting 2 to 6 hours
45
.
Midazolam
It is a benzodiazepine with good sedative and hypnotic acti-
vities, being twice to four times more potent than diazepam,
with fast onset of action, and can cause amnesia
46
. Its plas-
ma-cerebral balance time (T
1/2
Ke0) is between 0.9 and 5.6
minutes, and 87.5% of this balance occurs in 2.7 minutes
46
.
The elimination half-life in severely ill newborns is prolonged
(6.5 to 12 hours), and its clearance is decreased (0.07 to
0.12 L.h
-1
.kg
-1
). It can cause respiratory depression and hy-
potension, which are potentiated by the concomitant admi-
nistration of opioids, and it can cause addiction if used
continuously for more than 48 hours
1
. Although it is an
effective sedative when compared with placebo, one cannot
reach definitive conclusions about its safety in newborns
47,48
.
Its bolus, intermittent, intravenous, doses vary from 0.05 to
0.20 mg.kg
-1
every 2 to 4 hours, with onset of action in 1 to
3 minutes, peak action in 3 to 5 minutes, and duration of 1
to 2 hours. The doses for continuous intravenous adminis-
tration vary from 1 to 6 g.kg
-1
.min
-1 1,10
. Intranasal adminis-
tration is not recommended due to the risk of central nervous
system toxicity when it is absorbed, since it is in direct con-
tact with the olfactory nerve through the cribriform plate
49
. A
possible side effect is the development of seizures with fast
administration of elevated doses
50
. It can also reduce blood
flow to the medial cerebral artery in premature neonates
51,52
,
besides transient neurological effects (hypertonia, hypotonia,
choreic movements, dyskinetic movements, myoclonia, and
epileptic activity).
The data available is not enough to promote its continuous
infusion as a sedative in neonates in Neonatal Intensive
Care Units. Although midazolam is often used indiscrimi-
nately in Neonatal Intensive Care Units, alone or associated
with fentanyl, it has been demonstrated that the continuous
infusion in premature neonates is associated with severe
adverse effects such as death, leucomalacia, and peri-intra-
ventricular hemorrhage
48
.
Antagonists of Benzodiazepines and Opioids
The availability of specific antagonists of benzodiazepines
and opioids increased the safety of sedation for procedures, be-
cause respiratory depression can be reversed immediately
10
.
Naloxone is a non-selective opioid antagonist, extremely po-
tent, and 1 to 4 g.kg
-1
should be used to reverse the respira-
tory depression caused by opioids. Since it has a short
half-life (elimination half-life of 60 minutes), most patients
might need repeated doses, continuous infusion, or intra-
muscular deposit, besides monitoring, to avoid the rebound
effect of sedation and respiratory depression. It counteracts
not only respiratory depression, muscle rigidity, and gastroin-
testinal effects, but also sedation and analgesia
23
.
Flumazenil is a pure benzodiazepine antagonist that pre-
sents competitive inhibition of the GABA-diazepine complex
in the central nervous system. It is used to reverse the seda-
tive effects of benzodiazepines after sedation or intoxication.
The duration of its action is shorter than most benzodia-
zepines. The antagonism begins one to two minutes after the
intravenous administration, with a peak in six to 10 minutes.
The dose varies from 4 to 20 g.kg
-1
, and its side effects in-
clude nausea, vomiting, tinnitus, headache, seizures, anxiety,
and emotional lability
1,53
.
Newborn Withdrawal Syndrome
If during the withdrawal or after discontinuation of the drugs
used for sedation and analgesia signs and symptoms of
withdrawal, such as tachycardia, agitation, diaphoresis, nau-
sea, vomiting, diarrhea, sleep disorders, and even rebound
pain develop, one should consider instituting withdrawal
SEDATION AND ANALGESIA IN NEONATOLOGY
586 Revista Brasileira de Anestesiologia
Vol. 57, N
o
5, Setembro-Outubro, 2007
treatment involving several therapeutic options like metha-
done, phenobarbital, lorazepam, or an association of those
drugs
8,10
. Monitoring of withdrawal symptoms can be done
using the proper scale, as the Finnegan scale
54
.
CONCLUSION
Morphine has been recommended as the drug of choice,
according to a worldwide consensus on newborn sedation
and analgesia. However, morphine is not always the best
option for analgesia and sedation of premature neonates,
since it has been observed in this age group (gestational age
of 27 to 29 weeks) a statistically significant difference in the
incidence of severe peri-intraventricular bleeding in patients
who received continuous infusion of morphine
55
. Besides,
morphine metabolism depends on renal and hepatic func-
tion, and residual sedation has been implicated in the delay
to extubate those patients. Pharmacokinetic studies of mor-
phine present considerable variability in term newborns and
premature neonates, and morphine clearance is reduced in
premature neonates
56,57
.
Besides, several studies have demonstrated the safety and
efficacy of remifentanil in analgesia and anesthesia of new-
borns, at term and premature
32,33,58
. Since remifentanil does
not have residual sedation after it is discontinued, it be-
came an option for sedation and analgesia of premature
neonates
59,60
.
REFERNCIAS REFERENCES
01. Guinsburg R Avaliao e tratamento da dor no recm-nasci-
do. J Pediatr (RJ), 1999;75:149-160.
02. Franck LS, Lawhon G Environmental and behavioral strategies
to prevent and manage neonatal pain. Semin Perinat, 1998;
22:434-443.
03. Anand KJ Clinical importance of pain and stress in preterm
neonates. Biol Neonate, 1998;73:1-9.
04. Chermont AG, Guinsburg R, Balda RCX et al. O que os pedia-
tras conhecem sobre avaliao e tratamento da dor no recm-
nascido? J Pediatr (RJ), 2003;79:265-272.
05. Walco GA, Cassidy RC, Schechter NL Pain, hurt and harm.
The ethics of pain control in infants and children. N Engl J Med,
1994;293:918-919.
06. Bauchner H, May A, Coates E Use of analgesic agents for
invasive medical procedures in pediatric and neonatal intensive
care units. J Pediatr, 1992;121:647-649.
07. Barker DP, Rutter N Exposure to invasive procedures in neo-
natal intensive care admissions. Arch Dis Child, 1995;72:47-48.
08. Anand KJ International Evidence-Based Group for Neonatal
Pain Consensus statement for the prevention and management
of pain in the newborn. Arch Pediatr Adolesc Med, 2001;
155:173-180.
09. Menon G, Anand KJ, McIntosh N Practical approach to
analgesia and sedation in the neonatal intensive care unit. Se-
min Perinatol, 1998;22:417-424.
10. Machado MGP, Barbosa RFB, Silva YP A dor em neonatologia,
em: Silva YP, Silva JF Dor em Pediatria. Rio de Janeiro, Gua-
nabara Koogan, 2006;105-115.
11. Gray L, Miller LW, Philipp BL et al. Breastfeeding is analgesic
in healthy newborns. Pediatrics, 2002;109:590-593.
12. Blass EM, Hoffemeyer LB Sucrose as an analgesic for
newborn infants. Pediatrics, 1991;87:215-218.
13. Rebouas EC, Segato EN, Kishi R et al. Effect of the blockade
of mu1-opioid and 5HT2A-serotonergic/alpha1-noradrenergic
receptors on sweet-substance-induced analgesia. Psychophar-
macology, 2005;179:349-355.
14. Stevens B, Yamada J, Ohlsson A Sucrose for analgesia in
newborn infants undergoing painful procedures. Cochrane Data-
base Syst Rev, 2004;3:CD001069.
15. Stevens B, Yamada J, Beyene J et al. Consistent management
of repeated procedural pain with sucrose in preterm neonates:
is it effective and safe for repeated use over time? Clin J Pain,
2005;21:543-548.
16. Aranda JV, Carlo W, Hummel P et al. Analgesia and sedation
during mechanical ventilation in neonates. Clin Ther, 2005;27:
877-899.
17. Lyn YC, Sussman HH, Benitz WE Plasma concentrations after
rectal administration of acetaminophen in preterm neonates.
Paediatr Anaesth, 1997;7:457-459.
18. Taddio A Opioid analgesia for infants in the neonatal intensive
care unit. Clin Perinatol, 2002;29:493-509.
19. Bellu R, de Waal KA, Zanini R Opioids for neonates receiving
mechanical ventilation. Cochrane Database Syst Rev, 2005;
1:CD004212.
20. Camu F, Vanlersberghe C Pharmacology of systemic anal-
gesics. Best Pract Res Clin Anaesthesiol, 2002;16:475-488.
21. Bhat R, Chari G, Gulati A et al. Pharmacokinetics of a single
dose of morphine in preterm infants during the first week of
life. J Pediatr, 1990;117:477-481.
22. Bhat R, Chari G, Iver R Postconceptual age influences phar-
macokinetics and metabolism of morphine in sick neonates. Pe-
diatr Res, 1994;35:81A.
23. Stoelting RK, Hiller SC Opioids agonists and antagonists, em:
Stoelting RK, Hiller SC Pharmacology & Physiology in Anes-
thetic Practice, 4
th
Ed, Philadelphia, Lippincott Williams & Wilkins,
2006;87-126.
24. Franck LS, Miaskowski C The use of intravenous opioids to
provide analgesia in critically ill, premature neonates: a research
critique. J Pain Symptom Manage, 1998;15:41-69.
25. Chay, PC, Duffy BJ, Walker JS Pharmacokinetics-pharmaco-
dynamic relationships of morphine in neonates. Clin Pharmacol
Ther, 1992;51:334-342.
26. Fahnenstich H, Steffan J, Kau N et al. Fentanyl-induced chest
wall rigidity and laryngospasm in preterm and term infants. Crit
Care Med, 2000;28:836-839.
27. Meistelman C, Benhamou D, Barre J et al. Effects of age on
plasma protein binding of sufentanil. Anesthesiology, 1990;
72:470-473.
28. Glass PS Remifentanil: a new opioid. J Clin Anesth, 1995;7:558-
563.
29. Hoke JF, Shlugman D, Dershwitz M et al. Pharmacokinetics
and pharmacodynamics of remifentanil in persons with renal
failure compared with healthy volunteers. Anesthesiology, 1997;
87:533-541.
30. Eck JB, Lynn AM Use of remifentanil in infants. Paediatr
Anaesth, 1998;8:437-439.
31. Ross AK, Davis PJ, Dear GD et al. Pharmacokinetics of re-
mifentanil in anesthetized pediatric patients undergoing elective
surgery or diagnostic procedures. Anesth Analg, 2001;93:1393-
1401.
32. Sammartino M, Bocci MG, Ferro G et al. Efficacy and safety
of continuous intravenous infusion of remifentanil in preterm in-
fants undergoing laser therapy in retinopathy of prematurity:
SILVA, GOMEZ, MXIMO ET AL.
Revista Brasileira de Anestesiologia 587
Vol. 57, N
o
5, Setembro-Outubro, 2007
clinical experience. Paediatr Anaesth, 2003;13:596-602.
33. Silva YP, Gomez RS, Barbosa RF et al. Remifentanil for
sedation and analgesia in a preterm neonate with respiratory
distress syndrome. Paediatr Anaesth, 2005;15:993-996.
34. Anderson BJ, Palmer GM Recent developments in the
pharmacological management of pain in children. Curr Opin
Anaesthesiol, 2006;19:285-292.
35. Acharya AB, Bustani PC, Phillips JD et al. Randomised
controlled trial of eutectic mixture of local anaesthetics cream
for venepuncture in healthy preterm neonates. Arch Dis Child
Fetal Neonatal Ed, 1998;78:F138-142.
36. Kleiber C, Sorenson M, Whiteside K et al. Topical anesthesics
for intravenous insertion in children: a randomized equivalency
study. Pediatrics, 2002;110:758-761.
37. Stoelting RK, Hiller SC Barbiturates, em: Stoelting RK, Hiller SC
Pharmacology & Physiology in Anesthetic Practice, 4
th
Ed, Phi-
ladelphia, Lippincott Williams & Wilkins, 2006;127-139.
38. Wolf AR Neonatal sedation: more art than Science. Lancet,
1994;344:628-629.
39. Ambuel B, Hamlett KW, Marx CM et al. Assessing distress in
pediatric intensive care environments: the COMFORT scale. J
Pediatric Psychol, 1992;17:95-109.
40. Charney DS, Mihic JS, Harris RA Hypnotics and sedatives, em
Goodman and Gilmans the pharmacological basis of therapeu-
tics, 10
th
Ed, New York, Mc Graw-Hill, 2001:569-620.
41. Stoelting RK, Hiller SC Nonbarbiturate Intravenous Anesthetic
Drugs, em: Stoelting RK, Hiller SC Pharmacology & Physiology
in Anesthetic Practice, 4
th
Ed, Philadelphia, Lippincott Williams &
Wilkins, 2006;155-178.
42. Murdoch S, Cohen A Intensive care sedation: a review of
current British practice. Intensive Care Med, 2000;26:922-928.
43. Badr AE, Mychaskiw GH 2
nd
, Eichhorn JH Metabolic acidosis
associated with a new formulation of propofol. Anesthesiology,
2001;94:536-538.
44. Gear RW, Miaskowski C, Heller PH et al. Benzodiazepine
mediated antagonism of opioid analgesia. Pain., 1997;71:25-29.
45. Lago PM, Piva JP, Garcia PC et al. Analgesia e sedao em
situaes de emergncia e unidades de tratamento intensivo
peditrico. J Pediatr (RJ), 2003;79:223-230.
46. Stoelting RK, Hiller SC Benzodiazepines, em: Stoelting RK,
Hiller SC Pharmacology & Physiology in Anesthetic Practice,
4
th
Ed, Philadelphia, Lippincott Williams & Wilkins, 2006;140-154.
47. Anand KJ, Barton BA, McIntosh N et al. Analgesia and se-
dation in preterm neonates who require ventilatory support:
results from the NOPAIN Trial. Arch Pediatr Adolesc Med, 1999;
153:331-338.
48. Ng E, Taddio A, Ohlsson A Intravenous midazolam infusion for
sedation of infants in the neonatal Intensive Care Unit. Cochrane
Database Syst Rev, 2003 1:CD002052.
49. Cot CJ Premedication and induction of anesthesia. ASA
Refresher course, 2001;164:1-5.
50. Montenegro MA, Guerreiro MM, Caldas JP et al. Epileptic
manifestations induced by midazolam in the neonatal period. Arq
Neuropsiquiatr, 2001;59:242-243.
51. Harte GJ, Gray PH, Lee TC et al. Haemodynamic responses
and population pharmacokinetics of midazolam following admi-
nistration to ventilated, preterm neonates. J Paediatr Child Heal-
th, 1997;33:335-338.
52. Van Straaten HL, Rademaker CM, de Vries LS Comparison of
the effect of midazolam or vecuronium on blood pressure and
cerebral blood flow velocity in the premature newborn. Dev Phar-
macol. Ther, 1992;19:191-195.
53. Zaw W, Knoppert DC, da Silva O Flumazenils reversal of
myoclonic-like movements associated with midazolam in term
newborns. Pharmacotherapy, 2001;21:642-646.
54. Finnegan LP Neonatal abstinence syndrome: assessment and
pharmacotheraphy, em: Neonatal Therapy: an update. Excerpta
Medica, 1986;122-146.
55. Anand KJ, Hall RW, Desai N et al. Effects of morphine anal-
gesia in ventilated preterm neonates: primary outcomes from the
NEOPAIN randomised trial. Lancet, 2004;363:1673-1682.
56. Lynn AM, Slattery JT Morphine pharmacokinetics in early in-
fancy. Anesthesiology, 1987;66:136-139.
57. McRorie TI, Lynn AM, Nespeca MK et al. The maturation of
morphine clearance and metabolism. Am J Dis Child, 1992;146:
972-976.
58. Stoppa F, Perrotta D, Tomasello C et al. Low dose remifentanyl
infusion for analgesia and sedation in ventilated newborns.
Minerva Anestesiol, 2004;70:753-761.
59. Silva YP, Gomez RS, Marcatto JO et al. Morphine versus
remifentanil for intubation preterm neonates. Arch Dis Fetal Neo-
natal Ed, 2007;92:F293-294.
60. Silva YP, Gomez RS, Marcatto JO et al. Early awakening and
extubating with remifentanil in ventilated preterm neonates.
Pediatric Anaesthesia, 2007 (no prelo).
RESUMEN
Silva YP, Gomez RS,

Mximo TA, Silva ACS Sedacin y Analgesia
en Neonatologa.
JUSTIFICATIVA Y OBJETIVOS: La importancia del estudio del
dolor en neonatologa se debe al hecho de que la sensacin de
dolor y de estrs significa sufrimiento e incomodidad para los recin
nacidos y, a pesar de ese conocimiento poco se ha hecho para
reducirlo. Dentro de esa revisin se discutieron: la prevencin del
dolor, las medidas no farmacolgicas ye farmacolgicas para su
tratamiento y la sedacin en recin nacidos.
CONTENIDO: Varias son las medidas no-farmacolgicas que
pueden ser tomadas con el objetivo de prevenir el dolor en Unida-
des de Terapia Intensiva Neonatal y tambin para hacer el ambi-
ente ms humanizado y menos estresante para los pacientes y sus
familiares. El tratamiento del dolor en el recin nacido consiste en
medidas no farmacolgicas (succin no nutritiva, glicosis) y farma-
colgicas (analgsicos no-opioides, opioides y anestsicos loca-
les). La sedacin en recin nacidos es producida por frmacos que
actan disminuyendo la actividad, la ansiedad y la agitacin del pa-
ciente, pudiendo conllevar a la amnesia de eventos dolorosos o no
dolorosos. La sedacin puede ser hecha a travs del uso de hidrato
de cloral, barbitricos, propofol y benzodiazepnicos.
CONCLUSIONES: La prevencin del dolor y la indicacin de
analgesia deben ser individualizadas y siempre consideradas en
todos los recin nacidos portadores de enfermedades potencial-
mente dolorosas y/o sometidos a procedimientos invasivos,
quirrgicos o no.
SEDATION AND ANALGESIA IN NEONATOLOGY